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USING THE 5 A’S TO HELP WOMEN QUIT Young Women & Tobacco.

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Presentation on theme: "USING THE 5 A’S TO HELP WOMEN QUIT Young Women & Tobacco."— Presentation transcript:

1 USING THE 5 A’S TO HELP WOMEN QUIT Young Women & Tobacco

2 Acknowledgements This training was developed by the North Carolina Preconception Health Campaign, a program of the North Carolina Chapter of the March of Dimes, under a contract and in collaboration with the North Carolina Division of Public Health, Women’s Health Branch. This material was developed through support provided by the Department of Health and Human Services, Office of the Assistant Secretary for Health, Office of Adolescent Health (grant #SP1AH000004).

3 Acknowledgements Many thanks to these agencies and individuals for their generosity in sharing their resources in the area of tobacco cessation for women:  The American College of Obstetrics and Gynecology  The North Carolina Health and Wellness Trust Fund  The UNC Center for Maternal & Infant Health  Judy Ruffin, Women’s Health Branch, NC Division of Public Health  Tish Singletary, Director of Training, NC Health & Wellness Trust Fund Specific resources used to guide the development of this training:  Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit.  You Quit Two Quit. Smoking Cessation: An Essential Maternal Child Health Intervention. ACOG Practice Bulletin, December  The National Preconception Curriculum and Resources Guide for Clinicians (Module 1: Preconception Care: What it is and what it isn’t).

4 Young Moms Connect Brings together community partners to address challenges faced by pregnant or parenting teens using collaborative, multi-faceted strategies One component of Young Moms Connect is training for health care providers on six maternal and child health best practices

5 MCH Best Practices Early entry and effective utilization of prenatal care Establishment and utilization of a medical home (for non- pregnant women) Reproductive life planning Tobacco cessation counseling using the 5 A’s approach Promotion of healthy weight Domestic violence prevention

6 Objectives Increase provider understanding about how smoking cessation relates to opportunistic preconception health counseling Increase provider awareness about trends in smoking before, during and after pregnancy (also by county) and the influencing role of the health care provider Increase provider awareness about the need for tobacco cessation in high need populations to improve birth outcomes

7 Objectives (continued) Improve provider counseling using the 5 A’s approach with all young women of childbearing age (and how this can be adapted for pregnant women who are ready and those who are not) Improve service delivery to extend provider practice standards for smoking cessation counseling services to 12 months postpartum Improve service delivery to address postpartum “relapse”

8 Objectives (continued) Increase provider awareness of reimbursement options for tobacco cessation counseling and pharmacotherapy options Increase provider awareness of resources for patients and providers for smoking cessation

9 What is preconception care? Identification of modifiable and non-modifiable risk factors for poor health and poor pregnancy outcomes before conception Timely counseling about risks and strategies to reduce the potential impact of the risks Risk reduction strategies consistent with best practices CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1)

10 Components of preconception care Giving protection  (i.e.: folic acid, immunizations) Managing conditions  (i.e.: diabetes, maternal PKU, obesity, hypertension, hypothyroidism, STIs) Avoiding exposures known to be teratogenic  (i.e.: medications, alcohol, tobacco, illicit drugs) CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1)

11 “Opportunistic” care Preconception care is for every woman of childbearing potential every time she is seen Every woman, every time CDC National Preconception Curriculum and Resources Guide for Clinicians (Module 1)

12 Every woman, every time Young women who are at risk of pregnancy Young women who are pregnant Young mothers who are postpartum Young mothers who are between pregnancies

13 Preconception health: Tobacco cessation Smoking during pregnancy is the most modifiable risk factor for poor birth outcomes For women who may become pregnant and who smoke, provide opportunistic care about tobacco cessation For women who are pregnant, use prenatal visits to reduce/eliminate tobacco use For post-partum women, use the post-partum period to re-assess and assist women with tobacco cessation ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011.

14 Maternal smoking during pregnancy Increased risk for mother of:  Preterm birth  Ectopic pregnancy  Placental complications  Spontaneous abortion  Stillbirth Cnattingius S. The epidemiology of smoking during pregnancy: Smoking prevalence, maternal characteristics, and pregnancy outcomes Nicotine Tob Res (2004)

15 Maternal smoking during pregnancy Increased risk for child of:  Low birth weight (causal association – twice as likely in smokers) 1  Sudden Infant Death Syndrome 1  Childhood respiratory illnesses 2  Learning disabilities and conduct disorders 1 If it were possible to eliminate smoking during pregnancy entirely, the infant mortality rate in North Carolina would drop 10-20%. 3 1 Women and smoking: A report of the Surgeon General. U.S. Dept. of Health and Human Services, Public Health Service, Office of the Surgeon General; Washington, DC, Hu FB, et al., Prevalence of asthma and wheezing in public schoolchildren: association with maternal smoking during pregnancy, Annals of Allergy, Asthma and Immunology 79(1): Rosenberg DC, Buescher PA. The Association of Maternal Smoking with Infant Mortality and Low Birth Weight in North Carolina, SCHS Studies No Raleigh, NC: North Carolina State Center for Health Statistics; 2002.

16 Infant Mortality, 2009 Rate per 1,000 live birthsDeaths North Carolina 7.91,006 Onslow County6.928 Nash County10.24 Rockingham Co Bladen County10.64 Wayne County NC State Center for Health Statistics, NC Infant Mortality Report, 2009, Table 1.

17 Low birth weight, Percent of live births North Carolina9.1 Onslow County7.9 Wayne County9.2 Rockingham County9.7 Nash County10.1 Bladen County10.3 NC State Center for Health Statistics, Trends in Key Health Indicators tables.

18 Smoking in North Carolina 20% of females ages define themselves as a current smoker  Ages 25-34: 22%  Ages 18-24: 19% 16% of females ages say they smoke every day Highest rates among women with low levels of educational attainment and/or high levels of poverty NC Behavioral Risk Factor Surveillance System, 2009

19 NC female adolescent tobacco use Female high school students who report using tobacco at least once in the last 30 days:  20% (any tobacco)  14% (cigarettes) 59% of female high school smokers report living with someone who smokes North Carolina Youth Tobacco Survey, 2009

20 Smoking during pregnancy Nationally between 12-20% of all pregnant women report smoking during pregnancy Current clinical guidelines: “Whenever possible pregnant smokers should be offered person-to-person psychosocial interventions that exceed minimal advice to quit. Clinicians should offer effective tobacco dependence interventions to pregnant smokers at the first prenatal visit as well as throughout the course of pregnancy.” Martin JA et al. Births: Final data for National vital statistics reports. Vol 52 no 10. National Center for Health Statistics Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services

21 Smoking during pregnancy, Number of womenPercent North Carolina70, Bladen County34116 Nash County75912 Onslow County1,82111 Rockingham County1,10921 Wayne County1,09712 NC State Center for Health Statistics, NC Residents # and % of births to mothers that reported smoking prenatally

22 Smoking in the perinatal period Time Period Percent of women reporting smoking Prior to pregnancy22 During last 3 months of pregnancy13 After pregnancy18 Continuously (before, during & after)12 PRAMS 2008

23 Smoking after pregnancy 18% of women reported smoking after pregnancy in North Carolina  Ages have the highest rates Of women who reported smoking before pregnancy, then quitting during pregnancy, roughly half began smoking again 3-6 months postpartum PRAMS 2008

24 Smokeless and non-cigarette tobacco use Increasing prevalence among young women Pose serious health risks for the woman and her fetus Not a safer alternative to smoking Does not help smokers quit There is NO safe form of tobacco Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services

25 Smoking cessation during pregnancy: A maternal-child health best practice Despite the well-known health risks associated with smoking during pregnancy, many women continue to smoke even after learning they are pregnant In a Cochrane review, successful smoking cessation during pregnancy resulted in a:  20% reduction in the number of low birthweight babies  17% decrease in preterm birth Lumley J, Oliver S, Water E. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2000; CD

26 A teachable moment Women are more likely to quit at this time than any other time in their lives Generally motivated to have a healthy baby Brief counseling sessions are proven to work but are generally not integrated into regular prenatal care Cessation rates are 80% higher for women who receive counseling than for women who attempt quitting on their own Even pregnancy specific, self-help materials alone increase cessation rates (vs. usual care) Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services For further discussion, see also: ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011.

27 What providers can do Move beyond screening and recommendations Provide brief smoking cessation counseling and use pregnancy-specific self-help materials Use the 5 A’s regularly with preconception, pregnant and post-partum patients Connect patients with support such as the NC Quitline Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services

28 Quotes from new moms “I would have appreciated more help to stop smoking during my pregnancy. I don’t think doctors emphasize that enough.” “I think doctors should advise patients to quit more aggressively.” PRAMS survey participants, 2007

29 The 5 As Easy to implement Evidence-based Clinical counseling approach Effective for most pregnant smokers Also works preconceptionally and during the post-partum period AskAdviseAssessAssistArrange Fiore MC et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. U.S. Department of Health and Human Services For further discussion, see also: ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011.

30 ASK: Patients who are pregnant Which of the following statements best describes your cigarette smoking? 1. I have NEVER smoked, or have smoked LESS THAN 100 cigarettes in my lifetime. 2. I stopped smoking BEFORE I found out I was pregnant, and I am not smoking now. 3. I stopped smoking AFTER I found out I was pregnant, and I am not smoking now. 4. I smoke some now, but I cut down on the number of cigarettes I smoke SINCE I found out I was pregnant. 5. I smoke regularly now, about the same as BEFORE I found out I was pregnant. AskAdviseAssessAssistArrange

31 ASK: Patients who are not pregnant Ask if she has ever smoked, or smoked fewer than 100 cigarettes in her lifetime Ask if she uses any of the following tobacco products: chewing or smokeless tobacco, little cigars or cigarillos, Hookah, snuff, melt in your mouth orbs, sticks or strips Ask if someone smokes inside her house, in her car, around her, or at her workplace AskAdviseAssessAssistArrange

32 ASK: Patients who are postpartum or between pregnancies Ask the patient to choose the statement that best describes her smoking status: 1. I have NEVER smoked or have smoked less than 100 cigarettes in my life. 2. I stopped smoking BEFORE I found out I was pregnant and am not smoking now. 3. I stopped smoking AFTER I found out I was pregnant and I am not smoking now. 4. I stopped smoking during pregnancy, but I am smoking now. 5. I smoked during pregnancy and I am smoking now. AskAdviseAssessAssistArrange

33 ASK Use a concerned, helpful tone when you ask about smoking Use a multiple choice format Use either a written survey or clinical interview AskAdviseAssessAssistArrange

34 ADVISE Strongly urge all tobacco users to quit Use clear language Use a strong tone Use a personalized message AskAdviseAssessAssistArrange

35 ADVISE: Link to motivational points Tailor to her personal situation Use positive language Focus on positive benefits of quitting Use appropriate motivational messages AskAdviseAssessAssistArrange

36 ADVISE: Acknowledge barriers “I know I’m asking you to do something that takes a lot of effort, but my best advice to you (and your baby) is to quit smoking. I also see from your questionnaire that you have a history of bronchitis and asthma. Quitting smoking will help you feel better (and provide a healthier environment for your baby).” AskAdviseAssessAssistArrange

37 ADVISE: Recent quitters to remain smoke-free Congratulate! Reiterate the importance of staying smoke free for her own health, any current or future pregnancies and any current or future children Let her know you will be asking about her smoking status in future visits AskAdviseAssessAssistArrange

38 ASSESS Assess the willingness of the patient to make a quit attempt within the next 30 days For women who are ready, move on to ASSIST For women not ready to try quitting or commit to quitting, use the 5 R’s AskAdviseAssessAssistArrange

39 The 5 R’s Relevance Risks Rewards Roadblocks Repetition

40 Relevance Patient should discuss why quitting would be personally relevant Help her identify motivational factors of her own Link the motivational factor to her personal situation Be specific Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. An Educational Guide from the American College of Obstetricians and Gynecologists.

41 Risks Ask her to list potential negative consequences of smoking If patient is unaware of risks, this is a teachable moment- share information Tailor risks for where she is in life  No pregnancies yet  Pregnant  Postpartum  Between pregnancies

42 Rewards Ask the patient to think about how quitting might benefit her and her family Give her examples tailored to her situation Use the patient’s history and comments about her smoking behavior to create a checklist of factors that will increase her motivation to quit

43 Roadblocks Ask the woman what she thinks her barriers to quitting are Talk through problem solving strategies Demonstrate tools

44 Repetition At each subsequent appointment ask if she has changed her mind about trying to quit Explain that many people have to try more than once to quit and that each new attempt to quit increases the likelihood of quitting for good Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. An Educational Guide from the American College of Obstetricians and Gynecologists.

45 ASSIST Set a quit date Use a direct approach Avoid dates of significant events such as a birthday or anniversary Use a Quit Contract or record the quit date in a patient education material AskAdviseAssessAssistArrange

46 ASSIST Assess/arrange for support in the smoker’s environment Provide pregnancy or post-partum specific, self-help smoking cessation materials & review with patient Help patient envision and have a plan for cravings, withdrawal symptoms and social situations Ask patient to prioritize 1 or 2 concerns or potential barriers Provide reinforcement through a congratulatory letter or phone call AskAdviseAssessAssistArrange

47 ASSIST Make a referral to the NC Quitline: QUITNOW  Trained cessation coaches have protocols for pregnant women and adolescents/young adults  Patients can also text COACH to to receive cessation advice via their mobile phones  Free, 8am-3am, 7 days a week  Fax referral service speeds up the process AskAdviseAssessAssistArrange

48 Assisting heavy smokers Pregnant women who smoke more than a pack a day and are unable to quit after the 5As and the 5Rs may need more help The NC Quitline is helpful for heavy smokers Intensive behavioral counseling may be necessary via referral

49 ARRANGE Make follow-up visits Repeatedly assess smoking status and, if she is a continuing smoker, encourage cessation For patients trying to quit these visits should allow time to:  Monitor progress  Reinforce the steps toward quitting  Promote problem solving skills to prevent relapse or quickly recover from relapse AskAdviseAssessAssistArrange Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking, 2011 Self Instructional Guide and Toolkit. An Educational Guide from the American College of Obstetricians and Gynecologists.

50 Postpartum relapse 45%-70% of women who quit smoking during pregnancy relapse within 1 year of delivery Relapse may be delayed or avoided among women who receive smoking cessation counseling during the postpartum period US Department of Health and Human Services. Women and Smoking: A Report of the Surgeon General McBride CM et al. Prevention of relapse in women who quit smoking during pregnancy. Am J Public Health 1999;89:

51 Preventing postpartum relapse Good documentation Use the 5 A’s at the postpartum visit Use positive language to counsel Reiterate messages of:  Risks to babies and children from smoke exposure  Make your home a SMOKE FREE ZONE  Praise for efforts to quit and stay quit

52 Treating postpartum relapse Reassure and encourage her to try again Ask her to:  Quit immediately and put it in writing  Get rid of all smoking materials  Talk about what worked initially and what may have led to the relapse  Prioritize smoking cessation over post-partum weight loss

53 Treating postpartum relapse Encouragement Review triggers Refer back to NC Quitline Refer back to self help materials Breastfeeding should always be encouraged If she is not breastfeeding, consider prescribing a pharmacologic aid Ensure that the patient has a medical home for follow up beyond the postpartum period

54 Activity

55 When the 5 A’s approach isn't enough Referral for intensive counseling with a specialized provider Pharmacotherapy options*  Nicotine replacement  Gum, patches, lozenges, nasal spray and inhalers *Careful consideration; benefits must outweigh the risks *Many experts do not consider using these as an option during pregnancy ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, You Quit Two Quit Practice Bulletin. Smoking Cessation: An Essential Maternal Child Health Intervention, 2009.

56 Pharmacotherapy and lactation Nicotine replacement therapies pass into breast milk The highest dose (21 mg) = 17 cigarettes in breast milk 14 mg and 7 mg result in much lower amounts of nicotine passing into breast milk Gum and lozenges pass variable amounts depending on how much is chewed and frequency of use Buproprion may reduce milk supply ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, You Quit Two Quit Practice Bulletin. Smoking Cessation: An Essential Maternal Child Health Intervention, 2009.

57 Pharmacotherapy for non-lactating postpartum women Good option for those women for whom behavioral interventions have not been effective All forms of nicotine replacement increase the success of a quit attempt by 50%-70% Stead LF et al. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No. CD pub3 You Quit Two Quit Practice Bulletin. Smoking Cessation: An Essential Maternal Child Health Intervention, 2009.

58 Reimbursement for smoking cessation counseling Not one-size-fits-all: Each facility should investigate reimbursement options to maximize their payments for this important service Facilities such as a health department or a hospital generally use a facility rate

59 Medicaid covers smoking cessation counseling Smoking cessation counseling CPT codes: – Intermediate visit (3-10 minutes) – Intensive visit (> 10 minutes) An appropriate tobacco-related diagnosis, such as ICD-9 code (tobacco abuse), must be filed in addition to the Evaluation and Management code and submitted with the CPT code For more information, go to:

60 Creating a supportive health care facility environment Implement a tobacco user identification system Dedicate specific staff to provide tobacco cessation treatment Educate and gain input from staff about implementing tobacco cessation services Assign one person to coordinate and monitor implementation Train staff on 5 A’s Adapt procedures to your specific setting Extend postpartum tobacco cessation services to 12 months post-partum ACOG. Smoking Cessation During Pregnancy: A Clinician's Guide to Helping Pregnant Women Quit Smoking, 2011.

61 Summary: 5 A’s 1. Ask: Systematically identify all tobacco users 2. Advise: Strongly urge all tobacco users to quit 3. Assess: Determine willingness to quit 4. Assist: Set a quit date, materials, problem solve 5. Arrange: Make plans to monitor smoking status, provide reinforcement, support and encouragement AskAdviseAssessAssistArrange

62 Summary Identify and counsel young women who use tobacco and are at risk for pregnancy The 5 A’s approach is an effective, evidence-based method of achieving smoking cessation during before, during and after pregnancy Maintaining cessation in the post-partum period is challenging and post-partum relapse is common Postpartum relapse can be prevented with proper postpartum screening, 5 A’s approach, and extended cessation services to 12 months postpartum


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